Head, Face, Neck & Eye Assessment Review

Head, Face & Neck: Core Anatomy and Landmarks

  • Bones & Sutures
    • Frontal, Parietal, Temporal, Occipital, Sphenoid, Ethmoid
    • Sutures: Coronal, Squamous, Lambdoid
    • Facial bones: Nasal, Lacrimal, Zygomatic, Maxilla, Mandible (ramus, body, mental foramen, alveolar margins)
    • Processes: Zygomatic, Mastoid, Styloid
    • External acoustic meatus—landmark for ear & cranial base exams
  • Glands & Viscera
    • Parotid, Submandibular, Sublingual salivary glands
    • Thyroid (isthmus, lobes) & Parathyroids
    • Trachea midline—any shift ⇒ emergency differential (e.g., tension pneumothorax)
  • Lymphatics (Regional)
    • Occipital, Posterior auricular, Pre‐auricular, Submental, Submandibular, Jugulodigastric, Superficial & Deep cervical, Posterior cervical, Supraclavicular
    • Drainage direction guides infection source tracing (e.g., tender occipital ⇒ inspect scalp)

Structure & Function Overview

  • Head protects brain; face conveys emotion & houses sensory organs
  • Neck supports head, houses major vessels/viscera, conduit for respiratory & digestive tracts
  • Musculature innervated by CN V (Trigeminal) for mastication & CN VII (Facial) for expression
  • Lymphatic system filters pathogens; nodes should be soft, movable, non-tender (<1 cm)

Headache Typology (Subjective ― PQRSTU)

  • Tension (Musculoskeletal)
    • Location: bilateral “band-like”
    • Character: viselike; gradual (30 min–days)
    • Triggers: stress, poor posture
    • Relieved by rest
  • Migraine (Vascular/Trigeminovascular)
    • Usually unilateral, throbbing (Aura ±)\text{(Aura ±)}
    • Rapid onset; peaks 1–2 h; lasts 4–72 h
    • Triggers: hormones, certain foods (MSG, chocolate), sleep deficit, sensory stimuli, weather
    • Associated: N/V, photophobia, prodrome
    • Relief: dark room, sleep
  • Cluster (Autonomic/CN V)
    • Strictly unilateral peri-orbital, “stabbing/burning”
    • Abrupt; peaks in minutes; lasts 45–90 min; may occur 1–2×/day for months
    • Triggers: alcohol, daytime napping, wind/heat
    • Associated: ipsilateral tearing, rhinorrhea, agitation
    • Relief: pacing, movement
  • Clinical vignette: Severe throbbing h/a starting while studying, relieved by lying down ⇒ Migraine (exam Q)

Additional Subjective Data (Head/Neck)

  • Head injury history (LOC? mechanism?)
  • Dizziness types:
    • Presyncope (light-headed, cardiovascular)
    • Vertigo objective (room spins) vs subjective (person spins) ⇒ vestibular cause
    • Disequilibrium—musculoskeletal/neurologic gait imbalance
  • Neck pain, limited ROM, lumps, swelling
  • Past surgeries (thyroidectomy, carotid endarterectomy)

Objective Exam (Head/Neck)

  • Skull: size, contour; palpate for lumps, tenderness, fontanels (infants)
  • Face: symmetry (CN VII), involuntary movements, edema, pigmentation
  • CN V (Motor & Sensory): clench teeth, resist opening; cotton wisp to forehead/cheeks/chin
  • CN VII: smile, frown, puff cheeks, show teeth, close eyes tightly
  • Neck: inspect, palpate trachea midline, thyroid (posterior or anterior approach; swallow water)
  • ROM: flexion, extension, rotation, lateral bending; test strength (CN XI with shoulder shrug, head turn against resistance)
  • Lymph nodes: systematic palpation using pattern; note size, mobility, tenderness, delimitation
  • If node abnormal ⇒ explore area it drains (e.g., tender occipital ⇒ assess scalp)

Aging Adult – Head/Neck

  • Prominent bones & orbits; skin sags from ↓ elasticity, subcutaneous fat, moisture
  • Senile tremors (benign head nodding, tongue protrusion)
  • ROM slow to avoid dizziness
  • Drooping submandibular glands mimic tumor but are normal
  • Subjective emphasis: dizziness & impact on ADLs (driving, housework, falls)

Common Abnormalities (Head/Neck)

  • Parkinson disease: mask-like flat affect, staring, drooling (CN VII hypokinesia)
  • Cushing syndrome: rounded “moon” face, red cheeks, hirsutism
  • Acromegaly: enlarged skull & facial bones from GH hypersecretion
  • Cachexia: sunken eyes, hollow cheeks—wasting illnesses
  • Hyperthyroidism (Graves): exophthalmos, goiter, tachycardia
  • Hypothyroidism (Myxedema): puffy, edematous face, periorbital edema, coarse hair
  • Bell palsy: unilateral CN VII paralysis; inability to wrinkle forehead, close eye, whistle
  • CVA (stroke): lower facial weakness sparing forehead; language deficits

Eye Anatomy – External

  • Upper/lower lids, palpebral fissure, canthi, caruncle, limbus, sclera, iris, pupil
  • Extra-ocular muscles (6):
    • Superior, Inferior, Medial, Lateral recti; Superior & Inferior obliques
    • Innervation: CN  IIICN\;III (most), CN  IVCN\;IV (Superior oblique), CN  VICN\;VI (Lateral rectus)

Eye Anatomy – Internal

  • Three concentric layers:
    • Sclera (fibrous)
    • Choroid (vascular): ciliary body, iris, pupil control, lens accommodation
    • Retina (neural): optic disc, macula, retinal vessels
  • Chambers: anterior & posterior (aqueous humor), posterior cavity (vitreous body)

Visual Reflexes & Physiology

  • Pupillary light reflex (CN II afferent, CN III efferent):
    • Direct—constriction of illuminated pupil
    • Consensual—simultaneous constriction of opposite pupil
  • Fixation: eye maintains object on fovea; smooth pursuit interrupted by nystagmus
  • Accommodation: near focus ⇒ lens rounds, pupils constrict, convergence of eyes

Aging Adult – Eyes

  • ↓ pupil size, tear production; lens stiffens causing Presbyopia (near vision loss from lens elasticity↓\text{lens elasticity}↓)
  • Need more light; slow dark adaptation ⇒ fall risk
  • Common diseases ↓ vision: cataracts (lens opacity), glaucoma (optic nerve neuropathy, ↑IOP), macular degeneration (central vision loss), diabetic retinopathy (leading cause <65 y)

Eye Subjective Data (PQRSTU)

  • Vision difficulty (acuity, blurring, blind spots)
  • Pain, photophobia
  • Strabismus, diplopia
  • Redness, swelling, watering, discharge (allergies, infection)
  • Ocular surgery, trauma
  • Corrective lenses, last Rx, hygiene
  • Self-care: protective eyewear, screens, driving
  • Older adult extras: stairs, night driving, last glaucoma test, cataract presence, dryness limiting activities

Eye Objective Data

  1. CN II – Acuity
    • Snellen chart at 20 ft; record fraction test distancedistance  normal  eye  sees  same  line\frac{test\,distance}{distance\;normal\;eye\;sees\;same\;line} (e.g., 2030\frac{20}{30} ⇒ pt sees at 20 ft what normal sees at 30)
  2. External inspection
    • Lids: ptosis, lesions; lashes outward, evenly distributed
    • Conjunctiva & sclera: clear, white; look for jaundice, injection
    • Lacrimal apparatus: palpate for tenderness, regurgitation of fluid
  3. Anterior segment
    • Cornea/lens: clarity with oblique lighting; arcus senilis (lipid ring, benign aging)
    • Iris/pupil: size (3-5 mm adult), shape, equality
  4. CN II – Peripheral Vision (Confrontation)
  5. CN III, IV, VI – EOMs
    • Six cardinal fields (diagnostic positions test): note nystagmus, lid lag
    • Cover test for strabismus; Corneal light reflex (Hirschberg) for alignment
  6. CN III – Pupillary reflex
    • Darken room; shine light from side across pupil, watch direct & consensual constriction
    • Record as PERRLA: Pupils Equal, Round, Reactive to Light & Accommodation
    • Accommodation: focus distant ⇒ near (≈7 cm); observe convergence & constriction

Eye – Aging Adult Expected Findings

  • ↓ acuity (central & peripheral)
  • Loss of outer brow hair; remaining coarse
  • Sunken globes from atrophy; pseudo-enophthalmos
  • Dry, lusterless eyes; delayed tear production
  • Cloudy cornea possible; Arcus senilis gray ring; Xanthelasma yellow plaques on lids

Abnormal Eye Findings

  • EOM (Strabismus): esotropia (in), exotropia (out); paralysis pattern matches affected CN
  • Eyelids:
    • Periorbital edema (renal, allergy)
    • Ptosis (CN III palsy, Horner)
    • Exophthalmos (Graves) & Enophthalmos (dehydration, trauma)
    • Hordeolum (stye – infected follicle); Chalazion (meibomian cyst)
  • Pupil size disorders:
    • Mydriasis >6 mm (SNS, glaucoma drugs, brain injury)
    • Miosis <2 mm (parasympathetic, opioids, iritis)
  • Conjunctivitis: infection/allergy, preauricular node swollen
  • Iritis (Circumcorneal redness): photophobia, vision blur—urgent

Clinical Q&A (Integrated)

  • Severe throbbing h/a relieved lying ↓ while studying ⇒ Migraine
  • Tender, firm occipital node ⇒ examine scalp for infection (drainage basin)
  • Older pt asks about bony facial prominence ⇒ explain ↓ elasticity, subQ fat, moisture
  • Staring, flat affect, drooling ⇒ Parkinson history
  • Asymmetric smile/frown/forehead ⇒ CN VII damage
  • Presbyopia cause ⇒ loss of lens elasticity
  • Snellen 20/30 interpretation: patient reads at 20 ft what normal eye sees at 30 ft
  • Testing pupillary light reflex: shine light from side and observe direct & consensual constriction
  • Expected older-eye finding: arcus senilis, loss of brow hair (↑ tear production would be ABN)

Cranial Nerve Quick Reference

  • CN II – Optic: acuity, fields, fundus
  • CN III – Oculomotor: EOMs (except SO & LR), lid raise, pupil constrict
  • CN IV – Trochlear: Superior oblique (down/in)
  • CN V – Trigeminal: face sensation, mastication
  • CN VI – Abducens: Lateral rectus (out)
  • CN VII – Facial: expression, taste ant ⅔ tongue
  • CN XI – Spinal Accessory: sternomastoid/trap strength

Practical & Ethical Implications

  • Accurate documentation: only chart PERRLA if all elements assessed
  • Safety: impaired vision & dizziness in elderly ⇒ fall prevention, home modifications
  • Cultural competence: headache triggers (diet, stress) vary; tailor education
  • Screening: include glaucoma checks ≥40 y, diabetic retinal exams annually
  • Communication: clarify patient descriptors (“dizzy” vs “vertigo”) to target diagnostics